Referring Patients for Hospice Care
The most common complaint from patients and families about hospice care is that they were not informed about the practical benefits; there was too much talk about the philosophy of care and not enough about who would help and how. While managing symptoms and ensuring physical comfort are important, patients and families experience multiple issues that cause suffering and which lie in the practical, emotional, and spiritual domains.
When patients elect coverage using the MHB, the hospice coordinates and pays for all treatments and medications related to the primary hospice diagnosis. Patients can continue to receive care for diseases unrelated to the advanced illness (eg, continued dialysis for renal failure if the patient is dying of cancer) using regular Medicare coverage. Most Medicaid and commercial insurers use the Medicare Hospice Benefit Model for coverage of hospice care.
Medicare hospice benefit eligibility
To pay for hospice care, Medicare requires both the attending doctor and hospice doctor to certify that the patient has a life expectancy of 6 months or less if the disease or condition runs its normal course. The standard for certainty is "more likely than not"; in other words, the patient has a 51% or greater chance of dying in the next 6 months. If patients improve or resume disease-directed therapy with the primary goal of extending life-expectancy, they can be discharged and have their care paid for under the usual Medicare Part A, Part B, and Part D benefits. They can later elect the MHB and resume hospice services without penalty.
Individual patients can continue to be eligible for hospice if they live longer than 6 months, providing that the doctor believes death is more likely than not within 6 months. The patient does not need a do-not-resuscitate (DNR) order to be eligible for hospice care. There is no limit to the number of days that a patient can receive hospice care. There is no penalty if the patient outlives the initial prognosis. For example, one of the authors (CvG) had a patient with refractory breast cancer live for 6 years while enrolled in hospice care. At each recertification period, it was clear that the patient was more likely than not to die within 6 months because of her underlying disease. It was unforeseeable that this patient would live much longer than average.
When compared with actual survival, doctors overestimate prognosis by a factor of three or greater. For cancer, the most reliable indicator of prognosis is performance status—and this scientific fact has not changed in more than 40 years (Table 1).
Plan of care (POC)
The hospice program approves, coordinates, and pays for services that are reasonable and necessary for palliation and for management of the advanced illness. The POC is based on the patient's diagnosis, needs, goals of care, orders of the attending doctor, and, as necessary, collaboration with the hospice medical director. It includes caregiver education and support for the patient and family as the unit of care. It is surprising to many doctors that the hospice team can spend considerable time with the patient's family members to address their concerns and help in decisions that can significantly affect the wellbeing of the patient.
The POC is quite specific to individual hospice programs. Some care plans will include chemotherapy, radiotherapy, blood transfusions, antibiotics, laboratory testing, radiological imaging, and total parenteral nutrition (TPN), among other interventions when they are likely to make the patient feel better. Other, usually smaller, hospice programs will not be able to provide these interventions as part of the plan of care because of availability and cost. The MHB includes no rules about what may or may not be incorporated into the plan of care.
The attending doctor is indicated by the patient at the time of enrollment. This can be the patient's oncologist. Sometimes the patient will select a hospice doctor for this role. Sometimes the oncologist will request that the hospice doctor be the attending physician for the purposes of hospice enrollment, to deal with ordering and renewing medications; other oncologists prefer to retain this role.
The attending doctor is responsible for working with the hospice team to direct care. Direct patient care services by the attending doctor are billed to Medicare in the usual fashion using the standard Evaluation and Management codes.
Places of care
Home. The majority (95%) of hospice care days take place in the home because that is where patients say they want to be. Hospice team members visit the patient and family on an intermittent basis. Care continues as long as the patient remains eligible and wants the care. Medicare rules do not require a primary caregiver to be in the home; many patients live alone and like it that way!
Nursing home or other long-term care facility. This is the patient's home, and the patient's "family" frequently includes the staff. Hospice care is specialty care provided in addition to usual nursing home care.
Hospice inpatient unit. Dedicated units are sometimes available which are free-standing or located within other facilities such as nursing homes or hospitals. Permitted length-of-stay varies, as some units are for residential care and others are for short-term acute palliative care.
Hospital. Occasionally pain and other symptoms or other conditions related to the advanced illness cannot be managed at home and the patient is admitted to an inpatient hospital or other contracted inpatient facility for more intensive management. The inpatient facility must have a contract with the hospice program.
Payment to the hospice
Medicare pays for covered services using a per diem capitated arrangement in one of four categories:
• Routine home care: Care at home or in a nursing home.
• Inpatient respite care: Care in an inpatient setting (usually a nursing home or inpatient hospice unit) for up to 5 days, to give family caregivers a break when the patient is otherwise clinically stable.
• General inpatient care: Acute inpatient care for conditions related to the advanced illness (eg, pain and symptom control, caregiver breakdown, impending death and the patient does not want to die at home).
• Continuous home care: Provides short-term acute care at home with around-the-clock care for a crisis that might otherwise lead to inpatient care. Many hospice programs find this type of care challenging to provide, because of the staffing requirements.
Payment to attending and consulting doctors
Direct patient care services by the attending doctor for care related to the advanced illness are covered by Medicare, but not under the MHB.
If the attending doctor is not associated with the hospice program, the doctor bills Medicare Part B in the usual fashion. The bill must indicate that the doctor is not associated with the hospice program, or the claim may be denied. If the attending is associated with the hospice program or is a consultant, the doctor submits the bill to the hospice program, which in turn submits the claim to Medicare under Part A. The doctor is reimbursed based on a contract with the hospice program.
What do patients and families want to know about hospice care?
Patients and their families are most interested in "what [they] get" from enrolling in home hospice care. They do not usually learn about these benefits from their doctor; rather, they are told about them by a representative from the hospice, or from a friend or someone who has used hospice services before. They do not need to know about the "philosophy" of hospice care; they need to know practical assistance will be provided in the tasks of caring and in terms of case management; and that medications related to the treatment of the advanced illness, as well as supplies and equipment, are provided without cost to the patient.